Today's call case

[PoorInvestment]

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Lady lands in the ER G2P1 at 39 week, prior C section for arrest of labor. She has a nasty right spiral Tib/fib fracture. No prenatal care except for a midwife and her plan is to have a VBAC at home under the care of the midwife and adamantly refuses C/S. What's the plan?

 

[Arch Guillotti]

Pent. Sux. Tube.

 

[Velefunt]

Prop.Sux.Tube, +/- us-guided fem/sciatic nerve blocks with 0.5% bupiv w/ epi + PF dexamethasone for post-op pain

 

[Spinach Dip]

Retrograde intubation.

😛

 

[Hoya11]

Lady lands in the ER G2P1 at 39 week, prior C section for arrest of labor. She has a nasty right spiral Tib/fib fracture. No prenatal care except for a midwife and her plan is to have a VBAC at home under the care of the midwife and adamantly refuses C/S. What's the plan?

CSE. with a full dose spinal. epidural catheter for insurance if the case runs over.

 

[Icefrog]

Agree, fracture needs to be fixed so I'd probably prop, sux, tube assuming assuring airway. Could do a spinal too for the tib/fib if surgeon and patient are okay with it--it would limit the patient's exposure to anesthetic agents. OB consult and fetal heart monitoring.

 

[deleted162650]

Put her in a cast and send her home to VBAC.

 

[deleted87051]

Put her in a cast and send her home to VBAC.

Hahaha! If she doesn't believe in modern obstetrical care she probably doesn't believed in modern orthopedics either. Tell her you don't want to poison her or her baby. It's just a conspiracy by big pharma and the medical industrial complex😉

 

[pgg]

Call ortho, do a spinal?

Can't force her to have the kid, though the tib nail or ex-fix or whatever might precipitate labor regardless of what anyone wants. It would be for the best, really.

 

[deleted59964]

Call obstetrics - do they want to do pre intra post op CTG?
Warn re risk of precipitating labor and fetal distress
Get experienced (not slow) surgeon
Do spinal if airway ok -- convert to GA if c section becomes necessary
Do cse if airway not ok -- (top up for c section in case it becomes necessary).

 

[vector2]

Single shot sciatic and fem with 0.5%, epi, clonidine, decadron. Ketafol gtt. Fast surgeon. Tube or cse if not tolerating. Monitor heart tones. Tell patient she's an idiot if she tries to deliver at home considering her clot risk with pregnancy, recent fx, surgery, and immobility.

 

[gasp]

Lady lands in the ER G2P1 at 39 week, prior C section for arrest of labor. She has a nasty right spiral Tib/fib fracture. No prenatal care except for a midwife and her plan is to have a VBAC at home under the care of the midwife and adamantly refuses C/S. What's the plan?

With the info given at this point, I would just do an Epidural and not even bother with a CSE. My reasoning is you can load it somewhat slowly and get a good block without much hemodynamic change which could be a problem if this nasty fracture potentially ends up becoming a bloody mess. Also, I would do FHR monitoring with OB in house just in case she changes her mind about that c/s if and/or when the baby ends up in trouble for any reason. If she does want a c/s if and/or when that happens, you can simply bolus the epidural again for a higher block. The reason I would not do a CSE (although it is a very reasonable option) is because if you end up with the c/s route, giving a large bolus of for example 2% Lido to achieve a higher block may potentially give you a high spinal. Oh and GA obviously can be done at any point of this surgery but it wouldn't be my first option. Just my 2 cents..

 

[Urzuz]

Single shot sciatic and fem with 0.5%, epi, clonidine, decadron. Ketafol gtt. Fast surgeon. Tube or cse if not tolerating. Monitor heart tones. Tell patient she's an idiot if she tries to deliver at home considering her clot risk with pregnancy, recent fx, surgery, and immobility.

If the patient is not tolerating the surgery during the case, how would you do a CSE? Also, what advantage do the single shot blocks+ketafol confer that a CSE does not?

Edit: To be clear, I'm just trying to push you like they will on the oral boards 😉

 

[Random Anesthesiologist]

Call ortho, do a spinal?

Can't force her to have the kid, though the tib nail or ex-fix or whatever might precipitate labor regardless of what anyone wants. It would be for the best, really.

That's my thought too. She's a multip and likely walking around with a little dilation then add this and she could go into labor quickly. Monitor fetus always, since the fracture isn't over her belly. And she'll need left uterine tilt.

I like CSE and staying far from the airway as possible. O/w prop, sux, tube with glidescope available if needed. If she sleeps, she gets ogt during case.

But who knows how it would really go down. There is a fracture, they must fix it.

 

[PoorInvestment]

My hope was to convince her to have a c/s, let her chill a few days, then fix the leg but that, as you can imagine, was a no-go. My plan for the leg was to CSE this lady after discussing the risk of causing labor, hypotension, clots, etc. Ortho gave her the out of closed reduction and splinting since the tibia was already in good alignment and she took that as an out with a 2 week window in which to deliver. OB read her the riot act about the lunacy of trying VBAC at home, apparently since her midwife is well known to our OB group and has an ugly tendency to produce dead babies. Really was not excited about taking care of this lady but she really was not going to listen to reason. You can't save some people from themselves

 

[vector2]

If the patient is not tolerating the surgery during the case, how would you do a CSE? Also, what advantage do the single shot blocks+ketafol confer that a CSE does not?

Edit: To be clear, I'm just trying to push you like they will on the oral boards 😉

My thought is that the kind of lady who wants to vbac at home with a midwife is the same kind who screams bloody murder at the mention of any elective epidural. If she is down with an initial cse then by all means could proceed with that plan as well and do postop blocks with 0.25%. If she's not tolerating the Mac I'd position her just like I would a csec pt on the table whose labor epidural isn't setting up dense enough after being dosed. Sit them straight up from the supine position while keeping their legs flat on the table and pop it in. This is how a couple of my ob anesthesia staff do it and it works like a charm if you have a couple assistants putting traction the neck/shoulders to keep the back curved.

 

[jl lin]

My hope was to convince her to have a c/s, let her chill a few days, then fix the leg but that, as you can imagine, was a no-go. My plan for the leg was to CSE this lady after discussing the risk of causing labor, hypotension, clots, etc. Ortho gave her the out of closed reduction and splinting since the tibia was already in good alignment and she took that as an out with a 2 week window in which to deliver. OB read her the riot act about the lunacy of trying VBAC at home, apparently since her midwife is well known to our OB group and has an ugly tendency to produce dead babies. Really was not excited about taking care of this lady but she really was not going to listen to reason. You can't save some people from themselves

OMG. This absolutely insane. Even her MW should tell her how stupid this is. I had a VBAC, and it was grueling and really a bit on the risky side--pushed for many hours. Bled like an absolute pig. Huge baby. Shoulder dystocia on top of everything else, broke my coccyx (painful) and cut from one end to the other. Thank God I was in the hospital and my OB knew what the hell he was doing--especially since I was HR. Holy God! How is this even allowed--a VBAC w/o OB and anesthesia back up--in the home of all places? And w/ a serious T/F fx? WTH?

 

[Urzuz]

My thought is that the kind of lady who wants to vbac at home with a midwife is the same kind who screams bloody murder at the mention of any elective epidural. If she is down with an initial cse then by all means could proceed with that plan as well and do postop blocks with 0.25%. If she's not tolerating the Mac I'd position her just like I would a csec pt on the table whose labor epidural isn't setting up dense enough after being dosed. Sit them straight up from the supine position while keeping their legs flat on the table and pop it in. This is how a couple of my ob anesthesia staff do it and it works like a charm if you have a couple assistants putting traction the neck/shoulders to keep the back curved.

So the lady won't consent to a CSE as initial management, but will consent it DURING the procedure, after the surgeon has made his incision, with the drapes on and all? You would still plan on doing a CSE in the middle of a case? What if her BMI is 50? You think it'll be easy to just "pop" in a CSE with a pregnant lady with a gravid uterus in suboptimal positioning?

Also, what are the implications in your blocks just "not working" adequately? Let us say you start the case and everything seems okay, but then she starts to wiggle, and her BP shoots up to 260/170. Are there any special considerations in this lady in particular versus a regular old ASA 1 patient who walks through the door with a tib/fib fracture?

And you want run Ketafol in a patient who is 39 weeks pregnant? Aren't you concerned about sedating a woman with a full stomach with her potential loss of airway reflexes?

 

[vector2]

So the lady won't consent to a CSE as initial management, but will consent it DURING the procedure, after the surgeon has made his incision, with the drapes on and all? You would still plan on doing a CSE in the middle of a case? What if her BMI is 50? You think it'll be easy to just "pop" in a CSE with a pregnant lady with a gravid uterus in suboptimal positioning?

It's a discussion you have to have with the patient and the surgeon before the procedure. We can attempt the regional/Mac, if it doesn't work you get sat up. If pt doesn't want neuraxial period then you get a tube. My ob population is almost universally Bmi 30+ and the last time I did the sit up maneuver was on a Bmi 42 and it did just "pop in" first attempt. Done correctly with an experienced operator I don't think the success rate is significantly lower, although this is anecdotal.

Also, what are the implications in your blocks just "not working" adequately? Let us say you start the case and everything seems okay, but then she starts to wiggle, and her BP shoots up to 260/170. Are there any special considerations in this lady in particular versus a regular old ASA 1 patient who walks through the door with a tib/fib fracture?

And you want run Ketafol in a patient who is 39 weeks pregnant? Aren't you concerned about sedating a woman with a full stomach with her potential loss of airway reflexes?

The implications of the blocks not working (itself a highly unlikely scenario in an otherwise healthy pregnant pt whose ultrasound anatomy is likely pristine) is that she gets neuraxial or GA. Preop bicitra, reglan, Pepcid, glyco is a given which I didn't mention. Obviously the ideal scenario is that she gets no sedation, but most folks can't tolerate the sound of their bones being hammered/sawed/nailed even if they can't feel it. I would be modestly concerned if one were attempting deeeep sedation to the point of loss of airway reflexes, but running Ketafol (0.25-0.5mg ket/cc) at 25-50mcg/kg/min is imo profoundly effective at keeping a pt asleep, unresponsive to painful stimuli, and spontaneously breathing with intact reflexes. If she is requiring a high enough infusion rate that it could be considered deep sedation bordering on GA, she gets a neuraxial/tube.

 

[pgg]

How is this even allowed--a VBAC w/o OB and anesthesia back up--in the home of all places?

What do you mean, how is this allowed? It's a free country, even though some people keep trying to turn it into a nanny state.

People split lanes on motorcycles at 50 mph on LA freeways, eat rare steaks, jump out of perfectly good airplanes, and deliver babies at home. Whatcha gonna do?

Single shot sciatic and fem with 0.5%, epi, clonidine, decadron. Ketafol gtt. Fast surgeon. Tube or cse if not tolerating. Monitor heart tones. Tell patient she's an idiot if she tries to deliver at home considering her clot risk with pregnancy, recent fx, surgery, and immobility.

In my world, crazy people don't get elective peripheral nerve blocks, full stop.

You KNOW that when her idiot midwife wraps her right leg behind her left ear when she's sideways on the semi-submerged birthing ball in the kiddie pool water bath, she'll get some sciatic stretch and from there it's a direct line to suing you for causing her foot drop with your block. 😉

 

[Outrigger]

Get experienced (not slow) surgeon

Would love to work where the anesthesiologist gets to choose the surgeon. There are a few I would fire straight away and a few that would be on call 24/7.

 

[jl lin]

What do you mean, how is this allowed? It's a free country, even though some people keep trying to turn it into a nanny state.

People split lanes on motorcycles at 50 mph on LA freeways, eat rare steaks, jump out of perfectly good airplanes, and deliver babies at home. Whatcha gonna do?

Don't want a nanny state either; but this is one of the most idiotic things to me. It's stupid and in my opinion questionably ethical to me that the MW won't influence the patient to put mom and her baby first. Stunods.

 

[jl lin]

Don't want a nanny state either; but this is one of the most idiotic things to me. It's stupid and in my opinion questionably ethical to me that the MW won't influence the patient to put mom and her baby first. Stunods.

Sadly, maybe we will hear about it on 60 minutes.

 

[Random Anesthesiologist]

Stunod.

 

[PainDrain]

OB read her the riot act about the lunacy of trying VBAC at home, apparently since her midwife is well known to our OB group and has an ugly tendency to produce dead babies. Really was not excited about taking care of this lady but she really was not going to listen to reason. You can't save some people from themselves

How is this midwife even still practicing if she is leaving a trail of dead kids? I would have the OB contact the nursing board, if her record is that bad then she needs a real wake up call, like having her license pulled.

One thing to also consider is that this lady will likely need anticoagulantion for a while, she is a setup for a PE. I doubt she will take the lmw heparin but if she does she is going to bleed like hell whenever she does go into labor. Also, she is going to show up emergently for her section and you may not have the option of neuraxial due to the heparin.

 

[Arch Guillotti]

My thought is that the kind of lady who wants to vbac at home with a midwife is the same kind who screams bloody murder at the mention of any elective epidural. If she is down with an initial cse then by all means could proceed with that plan as well and do postop blocks with 0.25%. If she's not tolerating the Mac I'd position her just like I would a csec pt on the table whose labor epidural isn't setting up dense enough after being dosed. Sit them straight up from the supine position while keeping their legs flat on the table and pop it in. This is how a couple of my ob anesthesia staff do it and it works like a charm if you have a couple assistants putting traction the neck/shoulders to keep the back curved.

Are you going to do that once the surgery is underway?

 

[vector2]

Deep into the thick of things she gets a tube. If initial incision fails (like an allis), put a sterile towel over it, push some versed, and sit her up.

 

[deleted162650]

My hope was to convince her to have a c/s, let her chill a few days, then fix the leg but that, as you can imagine, was a no-go. My plan for the leg was to CSE this lady after discussing the risk of causing labor, hypotension, clots, etc. Ortho gave her the out of closed reduction and splinting since the tibia was already in good alignment and she took that as an out with a 2 week window in which to deliver. OB read her the riot act about the lunacy of trying VBAC at home, apparently since her midwife is well known to our OB group and has an ugly tendency to produce dead babies. Really was not excited about taking care of this lady but she really was not going to listen to reason. You can't save some people from themselves

See, told ya so. 😉 You can't fix stupid.

 

[teeva]

This one is easy. Inform the patient, respect her autonomy, document with excessive detail, and wash your hands of it.

Otherwise, for a reasonable pt, epidural/CSE for whichever surgery she needs with continuous fetal monitoring. Tube if it fails for whatever reason. Don't waste time fidgeting around with least to most invasive (block, then adding high dose sedation, then CSE, then GA) and lying the pt down/sit up/lie down again when you can just do one thing and have it work the first time around. This is a case where I wouldn't even offer a block.

 

[jl lin]

How is this midwife even still practicing if she is leaving a trail of dead kids? I would have the OB contact the nursing board, if her record is that bad then she needs a real wake up call, like having her license pulled.

One thing to also consider is that this lady will likely need anticoagulantion for a while, she is a setup for a PE. I doubt she will take the lmw heparin but if she does she is going to bleed like hell whenever she does go into labor. Also, she is going to show up emergently for her section and you may not have the option of neuraxial due to the heparin.

Well, there are different levels of education, and in some states, they are not even required to be licensed RNs. So, depending, the MW may not be a RN, . But certainly a VB is not "normal," and her situation is complicated now. Thanks but no thanks. This is just beyond insane to me.

Yes...wondering if she would even take LMWH, and yes, she is putting herself and baby at serious risk by not being followed by the right professionals. So, I am really wondering now if the MW is an actual RN that went on to become a MW, or if the person is simply a DE or CPM.

http://cfmidwifery.org/midwifery/faq.aspx#5

At any rate, this lady should definitely have a reputable BC OBGYN in charge of her care from the OB perspective. I can't think of one reputable RN that I work with, advanced practice or not, that would disagree. VBAC at home with a MW....lovely freaking story. Hope mom and baby somehow stay safe.

 

[Wiscoblue]

Why would an OBGYN want to be in charge of her? Give her enough rope and she will hang herself.

 

[OB1🤙]

I would do an isobaric tetracaine +epi spinal, and then sit there for hours while they do whatever they want to do with the leg.

I'd give her headphones and let her watch a movie on my phone if she got bored.

 

[PainDrain]

I'd give her headphones and let her watch a movie on my phone if she got bored.

You may also want to get her a snack, maybe bucket of KFC. She is pregnant, don't want her to starve or worse... She gets all "hangry" on you.

 

[deleted162650]

I would do an isobaric tetracaine +epi spinal, and then sit there for hours while they do whatever they want to do with the leg.

I'd give her headphones and let her watch a movie on my phone if she got bored.

This would essentially be my plan although I might be tempted to thread an epidural cath. Juuuuust in case baby started to take a dive on the FHR monitor and didn't respond to the usual measures I'd like to be able to dose her up for the C/S.

 

[jl lin]

Why would an OBGYN want to be in charge of her? Give her enough rope and she will hang herself.

I'm simply saying that is the professional that should be supervising her OB care, period. I'm not saying nurse-midwives (Yes, of course I would prefer those over non-nurse midwives.) don't ever have their place; but not for cases such as hers. Of course you are right in that there is only so much you can do, particularly when a client is recalcitrant and not willing to listen and be reasonably compliant. Obviously OB and delivery are not always as easy as just popping some child out in the middle of a rice paddy. Those people that contend midwifery is the main thing needed for pregnant women b/c it always was through the centuries are idiots that don't understand history and maternal/infant losses of the centuries. Whether she's stupid, stubborn, or whatever else, I would rather she not hang herself or add to potential harm to her baby. I'm kind of old fashioned that way.

 

[Planktonmd]

Femoral + Sciatic block.... move on

 

[deleted59964]

Would love to work where the anesthesiologist gets to choose the surgeon. There are a few I would fire straight away and a few that would be on call 24/7.

in this case - I mean, this isn't teaching case ...